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REASONS FOR SUBMISSION (PLEASE CHECK ONE) 2026
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How to use or fill out REASONS FOR SUBMISSION (PLEASE CHECK ONE) with our platform
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- Click ‘Get Form’ to open it in the editor.
- Begin by selecting your reason for submission. Check one box under 'REASONS FOR SUBMISSION' that best describes your situation: NEW ENROLLMENT/CONTRACT, CHANGE TO CONTRACT, or TERMINATE CONTRACT.
- Next, indicate the qualifying event date and check all applicable events from the list provided. This could include options like OPEN ENROLLMENT, NEW HIRE, or BIRTH/ADOPTION.
- In the 'REASON FOR CHANGES' section, check all reasons that apply to your changes. If you have other reasons not listed, specify them in the provided space.
- Fill out the EMPLOYER/GROUP INFO section completely as required by your employer. Ensure all necessary details are accurate.
- Complete the SUBSCRIBER INFORMATION section with your personal details including name, contact information, and primary care provider (PCP) selection if applicable.
- If applicable, provide information for any dependents you wish to enroll or change coverage for in the DEPENDENT INFORMATION sections.
- Finally, review all entries for accuracy before signing and submitting the form to your employer for processing.
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harvard pilgrim health enrollment form
When calling about a mailed submission, please have the TCN or DCN number, the subjects name, and the date the form was mailed to the BOI available. WhenRead more
REASONS FOR SUBMISSION (PLEASE CHECK ONE) OPEN ENROLLMENT ☐NEW HIRE ☐COBRA ☐LOSS OF URANCE ☐COURT ORDER ☐BIRTH/ADOPTION ☐MARRIAGE/DIVORCE ☐MOVED IN/OUT OF